Homerton doctor cleared of gross negligence
PUBLISHED: 15:32 10 January 2014 | UPDATED: 16:46 14 January 2014
A Finnish doctor from the Homerton who used a test banned in the UK eight years ago, which failed to show a feeding tube was inserted in a pensioner’s lung leading to her death, has been cleared of any negligence.
Grandmother Andriana Georgiou, 84, was admitted to Homerton Hospital in November 2012 for specialist treatment after a stroke.
As she could not feed herself, a naso-gastric feeding tube was used to give her nutrition but after she pulled it out on December 4, it was wrongly re-inserted into one of the retired clothes factory worker’s lungs instead of her stomach, Poplar Coroner’s Court was told at her inquest on Wednesday.
A pH test showed levels were abnormally inflated indicating the tube was not in the stomach, and senior nurse Sisphiwe Raseluma insisted an X-ray was booked, according to Trust policy.
But Kari Saastamoinen carried out a procedure known as the “whoosh test” – whereby air is syringed into the tube and a stethoscope used to determine whether the tube is correctly positioned.
A National Patient Safety Agency alert in 2005 and two subsequent warnings stated use of the “whoosh test” - which breaches Homerton Trust’s policy - must cease immediately.
Yet Dr Saastamoinen, who wanted the patient to be fed as soon as possible, demonstrated to five junior doctors how to perform it.
Although using the test as a stand alone assessment breached safety guidelines, he said he was happy with the result, and began feeding Mrs Georgiou.
Hours later she became critically ill, two litres of fluid was drained from her lungs and she was rushed to intensive care.
The mistake is believed to contributed to her death from pneumonia 11 days later on December 15.
Ms Raseluma told the proceedings she had been extremely concerned as she had been a nurse for 20 years and that the ‘whoosh test’ was something only used in the “olden days.”
She continued: “I had no idea I could escalate this but if it happened tomorrow I would take it to the medical directors, the most senior doctors in the hospital. I had never been in a situation of needing to go above the consultant.”
Giving evidence, neurologist Dr Saastamoinen - who was head of department for 20 years at Finland’s Helsinki hospital before he started at the Homerton in 2010 - said he had no idea the test commonly used in his home country was banned over here.
He described how he was “reluctant” to do a chest X-ray because there would have been a delay feeding Mrs Georgiou.
He claimed he was never shown hospital policy, and had not attended an induction at the Homerton until 2013 because timing was difficult because of his duties at the Royal London where he also works.
“It is important to follow policy but at the Royal London there have been three cases of wrong feeding, even though they have that same policy,” he said.
Mary Elizabeth Hassel, the senior coroner for North London said: “I’m trying to put myself into your shoes, deciding to perform the whoosh test and not the X-ray.
“I can see you didn’t want there to be a delay, you wanted feeding to start, but you have told me, “I haven’t been familiar recently in detecting whether the naso-gastric tube is in place, I have not done it at all in the three years since I came to the Homerton. Now I have a nurse saying to me when it’s a pH of 8 you need an X-ray, not even whether she mentioned it was the hospital policy, I have a lot of junior doctors who have never seen a whoosh test, but what I’m going to do is to perform a whoosh test and I’m not going to check the hospital policy.”
“Putting myself in your shoes there, it does seem a bit cavalier, do you think it was cavalier?”
Dr Saastamoinen’s barrister advised him not to answer.
John Coakley, medical director at the hospital in Homerton Row since 1998, apologised to Mrs Georgiou’s daughter, son and granddaughter for the event which happened on his watch.
“It’s easy to put the tube in the wrong place but the serious incident is failing to recognise that,” he said.
“The NHS describes it as a never-event but it happens 20 times a year on average and five patients die.
“Many incidents happen when people are trying to help people out, certainly this was an unfortunate lady.
“There’s a concern if patients are getting X-rays all the time they are spending more time in X-ray than on the ward, there’s a sense we don’t want to keep radiating people, it’s a humanitarian act to say let me show you this test, nearly always when people try to help they vary from protocol, that’s when things go wrong in healthcare.
“Protocols are there but they aren’t set in stone, if I want to do something against the rules I have to write up why and discuss with other people to guard myself against being accused of violating protocol, that involves listening to people and being right. Otherwise you’re in a serious position.
“Trust policy is there to be adhered to, particularly when it’s medically informed, whether it was pointed out or not it’s your responsibility as a clinician to be up to date with the policy.”
The coroner delivered a narrative conclusion, stating Mrs Georgiou - who had been bed-bound for six months, was obese and had high blood pressure - died as a combination of a stroke and the misplaced tube.
Ms Hassell said: “She was a poorly lady and clearly had some significant natural disease, but what I must decide is whether the misplaced tube was a contributory factor, and having listened very carefully I am persuaded on the balance of probabilities it was.
“The system wasn’t perfect but I do think it was good, the misplacement wasn’t detected because of individual errors.
She said the proof was not sufficient to decide gross negligence had occurred. “I’m satisfied there was a duty of care issue, but was that grossly negligent?” she asked.
“For that I must say that conduct was so bad and reprehensible it amounts to a crime, and I do not find that, I do find there were errors but they do not amount to a crime.”
Dr John White, a partner at Blake Lapthorn solicitors representing the family said ahead of the inquest the family were looking for answers.
“Feeding a patient down a tube misplaced in to the lungs is a so-called ‘never event’ that the NHS says it has resolved to prevent from ever occurring.”
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